Organ trafficking and illicit transplant surgeries have infiltrated global medical practice. But despite the evidence of widespread criminal networks and several limited prosecutions in countries including India, Kosovo, Turkey, Israel, South Africa and the US, it is still not treated with the seriousness it demands.

Since the first report into the matter in 1990, there has been an alarming number of post-operative deaths of “transplant tour” recipients from botched surgeries, mismatched organs and high rates of fatal infections, including HIV and Hepatitis C contracted from sellers’ organs. Living kidney sellers suffer from post-operative infections, weakness, depression, and some die from suicide, wasting, and kidney failure. Organs Watch documented five deaths among 38 kidney sellers recruited from small villages in Moldova.

Distressing stories lurk in the murky background of today’s business of commercialised organ transplantation, conducted in a competitive global field that involves some 50 nations. The World Health Organisation estimates 10,000 black market operations happen each year.

The organ trade network

As I wrote in Living Donor Organ Transplants, the sites of illicit transplant have expanded from Asia to the Middle East, Eastern Europe, South Africa, Central Asia, Latin America and the US. All are facilitated by local criminal networks but those run by organised global criminal syndicates are the most dangerous, mobile, and widespread. They are also the most difficult to trace and to interrupt.

The trade involves a network of human traffickers including mobile surgeons, brokers, patients, and sellers who meet for clandestine surgeries involving cut-throat deals that are enforced with violence, if needed. Many of the “kidney hunters” are former sellers, recruited by crime bosses into the tight web of transplant trafficking schemes.

Sellers include poor nationals, new immigrants, global guest workers, or political and economic refugees recruited from abroad to serve the needs of transplant tourists in countries that tolerate or actively facilitate the illegal transplant trade.

Bioethicists argue endlessly about the “ethics” of what is actually a crime and a medical human rights abuse.

Turning up the heat

In 2008, the climate of denial began to change when The Transplantation Society) and the International Society of Nephrology), held a major summit which acknowledged organ trafficking as a reality. Moral pressure was then put on countries actively involved in organised and disorganised international schemes to recruit paid, living donors.

Despite this, criminal networks of brokers and transplant trafficking schemes are still robust, exceedingly mobile, resilient, and generally one step ahead of the game. Meanwhile, one economic or political crisis after another has also supplied the market with countless refugees that fall like ripe fruit into the hands of organ traffickers. The desperate, displaced and dispossessed can be found and recruited to sell a spare kidney in almost any nation.

Who gets what?

Human trafficking for organs is still generally seen as a victimless crime that benefits some very sick people at the expense of other, more invisible - or at least dispensable - people. And some prosecutors and judges treat it as such.

In 2009, New Jersey federal agents arrested kidney trafficker Levy Izhak Rosenbaum as part of a larger police sting of corrupt politicians. Rosenbaum, a self-styled “matchmaker” as he described himself in taped conversations, was caught trying to arrange the private sale of a kidney from a donor in Israel to an undercover FBI agent for $160,000 (£100,000).

The hospitals where the Rosenbaum operations were arranged were prestigious and despite it being illegal to trade organs in the US since 1984, many don’t ask enough questions. Indeed, Rosenbaum claimed he was easily able to concoct cover stories. It’s a lucrative business.

Federal prosecutors couldn’t believe that the trafficked organ sellers had been deceived or coerced into selling. Two years later Rosenbaum pleaded guilty to just three incidents of brokering kidneys for payment despite admitting to having been in the business for over a decade.

At his trial, Rosenbaum had a powerful show of support from transplant patients who arrived to praise the trafficker, and beg for his mercy.

Only one victim of kidney selling testified - a young black Israeli, Elahn Quick - who was recruited by traffickers to travel to a hospital in Minnesota to sell his kidney to a 70-year-old man. Quick testified that he agreed to the donation because he had been unemployed, alienated from his community, and hoped a meritorious act would improve his social standing. However, just before he was anaesthetised he asked his “minder” if he could get out of the deal. The operation went ahead.

The judge, perhaps moved by Rosenbaum’s supporters, concluded that deep down he was a good man, and that Quick had not been defrauded; he was paid what he was promised. “Everyone”, she said, “got something out of this deal”.

Combating criminal networks

Illegal, clandestine kidney transplants depend on criminal networks of human traffickers preying on the bodies of both the desperately sick and poor.

Prosecutions of traffickers and their associates — brokers, kidney hunters, and enforcers — is inefficient. Brokers are the most visible players but easily replaceable. Arresting and prosecuting a few of them, as has been the case, won’t deter others from taking their place.

While culpable, kidney sellers and transplant tour recipients are also victims of recruitment, deception and varying degrees of coercion. They can provide information, but should be treated as victims unless, as happens in some cases, they go on to also become part of the trade.

Legislation and prosecution must instead focus on transplant professionals — the surgeons, hospitals, and insurance companies - that claim immunity by saying either that they can’t police the trade, or that they are not responsible for monitoring what goes on behind the scenes, or that they’ve been deceived.

Transplant professionals were implicated in the Netcare scandal in South Africa after the company entered into a plea bargain and accepted a $1.1m fine. The charges were related to 109 kidney transplants carried out between 2001-3. There were false declarations that donors were related and five operations in which the donors were minors, all against the company’s own internal policy.

Organs Watch has many copies of letters that show how organised traffickers can be, how they keep schemes quiet and how they coach kidney sellers and transfer illicit payments.

Professional medical sanctions against transplant surgeons who work with criminal organs trafficking networks are non existent but could be very effective. They should lose their license to practice medicine and be prohibited from participating in transplant conferences.

Regulation cannot come solely from within the transplant profession. Different laws and different jurisdictions make prosecutions of crimes that span international boundaries very difficult.